Annals of Family Medicine Tip Sheet

American Academy of Family Physicians

Understanding What Prevents Shared Decision Making From Wider Implementation With Black Patients

To understand the perspectives of Black patients on shared decision making (SDM) during medical appointments, researchers and clinicians investigated the preferences, needs and challenges around SDM as experienced by Black individuals. The team also offers possible adaptations and modifications for SDM models, practice and research within Black communities. The study team recruited 32 Black patients – 18 men and 17 women – with type 2 diabetes from safety-net primary care clinics caring for medically underserved racial and ethnic communities. The team conducted qualitative interviews, asking about unmet needs, challenges and what might help in facilitating SDM. The team asked about issues related to race, culture and disparities. At the end of the interviews, participants completed the 9-item Shared Decision Making Questionnaire (SDM-Q-9).

Four themes emerged from the interviews: The first was preferences for humanistic communication. Participants reported a desire for their doctors to express empathy, concern and compassion as part of the medical appointment. They also wanted communications that utilized first names between doctors and patients and wanted “ice breaker” communications including humor and conversations with them rather than talking at them. The second theme that emerged was the need for doctors to account for the central role of family members in decision-making to facilitate adherence and engagement with the prescribed treatment. The third was the need for more medical information, specifically about tests and treatments; and the fourth theme was a growing mistrust in doctors, especially when patients felt unseen to the doctor or staff. Zisman-Ilani et al also suggested actions to help doctors better communicate with patients. The team argue that their findings offer meaningful and necessary insights and recommendations for future use and adaptations to make SDM more valuable in the care of Black patients and other ethnoracial minorities.

What is Known on This Topic: Shared Decision Making (SDM) has been studied for several decades, but its implementation and use with Black and other ethnic and racial minority patients is limited.

What This Study Adds: Accommodations for SDM practice with Black patients in safety-net primary care settings are needed to make SDM more relevant and socioculturally sensitive to the experiences, needs and preferences of diverse groups of patients.

Disparities in Shared Decision-Making Research and Practice: The Case for Black American Patients

Yaara Zisman-Ilani, MA, PhD, et al

Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, Pennsylvania and Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, University College London, London, United Kingdom

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Survey of Family Physicians Identifies Gaps in Primary Care’s Behavioral Health Integration

Researchers from the American Board of Family Medicine (ABFM) and the University of Washington in Seattle examined the characteristics of family physicians who work collaboratively with behavioral health professionals (BHP). Prior evidence has demonstrated that integrating behavioral health into primary care can improve access to mental health care and patient health outcomes.

Almost 40% (38.8%) of 25,222 family practitioners reported working collaboratively with behavioral health professionals. Physician characteristics significantly associated with increased odds of BHP collaboration were being female (OR 1.09) and working as core/salaried faculty (OR 2.32) as compared to non-faculty. The strongest practice characteristic was working in a federally run practice site and the strongest negative association was working in an independently owned practice and being located in the Southern United States. Additionally, working in a county with more psychiatrists is associated with higher likelihood of BHP collaboration. Understanding these disparities could help improve behavioral health access for patients and improve overall patient outcomes.

What is Known on This Topic: Integrated behavioral health has been shown to improve mental health and overall health outcomes, patient care experience and clinician satisfaction, while reducing health care use and costs. However, not all family medicine practices offer integrated behavioral health services.

What This Study Adds: Almost 40% of family practitioners work collaboratively with behavioral health professionals. Physicians who were female; worked as core/salaried faculty; and worked in a federal practice site were more likely to work with integrated behavioral health. Gaps in access to integrated behavioral health were seen in independently owned practices and those located in the Southern United States.

Characteristics of Family Physicians Practicing Collaboratively With Behavioral Health Professionals

Sebastian T. Tong, MD, MPH, et al

University of Washington, Department of Family Medicine, Seattle, Washington

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Primary Care and Behavioral Health Integration in a Single Clinic Setting Can Improve Holistic Patient Care

Family physician Anne C. Jones, DO, and behavioral health consultant Kaitlin Lilienthal, PhD, describe a practice transformation that improved care experiences. Working closely together in a Primary Care Behavioral Health Model within a university setting, the authors describe their collaborative approach to helping a college student with a complex mix of physical and psychological symptoms. Similar to a musical ensemble, the authors describe key details of interdisciplinary collaboration that promotes holistic care for patients and a fulfilling biopsychosocial practice.

What is Known on This Topic: Many patients present with both physical and psychological symptoms in family practice settings. Integrated behavioral health can address all of the patients’ concerns in a coordinated way.

What the Results Mean: When health care teams work together to implement behavioral health into primary care (such as having a behavioral health consultant work with a primary care doctor in the same office), they can knit together a fragmented health care system and help patients overcome barriers to care.

Integrating Behavioral Health and Primary Care: Turning a Duet Into a Trio

Anne C. Jones, DO, MPH

Rowan University School of Osteopathic Medicine, Sewell, New Jersey

Kaitlin R. Lilienthal, PhD

Cayuga Integrated Behavioral Health, Cayuga Media Associated, Ithaca, New York

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Database Analysis of Commercially Available STI Tests Supports Vaginal Swabs as Most Reliable Detection Method

Researchers conducted a meta-analysis of multiple databases from 1995-2021 to assess the diagnostic sensitivity of commercially available tests that use vaginal swabs versus urine specimens to detect chlamydia, gonorrhea and trichomonas. Although vaginal swabs are the recommended sample type by the Centers for Disease Control and Prevention (CDC),, the most used specimen among women is urine. The authors identified 28 eligible articles with 30 comparisons for CT; 16 comparisons for NG; and nine comparisons for TV.

Vaginal swabs consistently performed somewhat better than urine tests in detecting STIs; however, for trichomonas, the odds ratio that vaginal swabs were more sensitive than urine did not reach statistical significance. For vaginal swabs and urine, respectively, pooled sensitivity estimates were 94.1% and 86.9% for CT; 96.5% and 90.7% for NG; and 98.0% and 95.1% for TV. The differences were statistically significant for chlamydia and gonorrhea.

The authors assert that this analysis supports the CDC’s recommendation that vaginal swabs are the optimal sample type for women being tested for chlamydia, gonorrhea and/or trichomonas. Relying on urine testing could result in an estimated 400,000 undetected cases of chlamydia and gonorrhea each year. While vaginal swab tests are the most sensitive for STI testing, urine testing is a reasonable alternative when swabs are not available or acceptable.

What is Known on This Topic: Chlamydia, gonorrhea and trichomonas are common and treatable sexually transmitted infections. Women bear a disproportionate burden of these infections and testing is necessary to identify infections. Although vaginal swabs are the recommended sample type, the most used specimen among women is urine.

What This Study Adds: Study results support the CDC’s recommendation that vaginal swabs are the optimal sample type for women being tested for chlamydia, gonorrhea and/or trichomonas. Additional implementation studies are needed to change practice patterns to use vaginal swabs rather than urine testing as the most common practice. Vaginal sampling should be the initial choice offered to patients and urine samples should only be considered for women for whom collection of a vaginal sample is not acceptable.

Vaginal Swab vs Urine for Detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis: A Meta-Analysis

Kristal J. Aaron, DrPH, MSPH, et al

University of Alabama at Birmingham, Department of Medicine, Division of Infectious Diseases, Heersink School of Medicine,

Birmingham, Alabama

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Pediatricians Challenge Fellow Doctors and Primary Care Clinicians to Adopt More Effective Adolescent STI Screening by Addressing Implementation Barriers

Wood and Fiks, this issue’s editorialists, cite Aaron et al’s study about the greater effectiveness of vaginal, compared to urine, samples for molecular detection of sexually transmitted infections (STIs) in sex-at-birth females, and describe it as a necessary shift in practice. They argue that transitioning to vaginal specimens in their patients could have a critical health impact by increasing early treatment and reducing downstream transmission of STIs. They assert that adopting more sensitive screening strategies also supports two key tenets of reproductive justice for patients entering their peak reproductive years, namely maintaining personal bodily autonomy and preserving the right to have children when desired.

They note that chlamydia screening rates for U.S. adolescents are far below targets, even using non-invasive urine testing. The authors call for the reduction of screening barriers, such as limited visit time, confidentiality concerns, implicit bias and clinician discomfort around discussing sexual health with adolescents. They also point out that vaginal sampling may require teaching patients how to self-sample or for clinicians to explain and collect specimens. Additionally, they foresee clinicians having to manage parental expectations.

Despite numerous barriers to vaginal testing implementation for STIs, Wood and Fiks affirm that Dr. Aaron et al provide sufficient data to demonstrate that defaulting to urine testing isn’t enough and that multiple cases of STI could go undetected. They recommend that vaginal testing be offered first and if it is not acceptable or feasible, then urine testing should be offered. “Family practitioners, pediatricians, and health systems will need to rise to this implementation challenge,” Wood and Fiks write. “By engaging now in implementation and quality improvement efforts with patients, physicians, clinic staff, and health systems, we can improve the quality, sensitivity, and reach of testing for adolescents and meaningfully improve adolescent health.”

What is Known on This Topic: This Annals of Family Medicine issue’s editorialists, both pediatricians, cite the Aaron study that posits vaginal testing as more effective than urine sampling in detecting sexually transmitted infections, including chlamydia, gonorrhea, and trichomonas. However, there are various barriers to adopting vaginal testing, particularly in adolescents.

What This Study Adds: Authors Wood and Fiks encourage family practitioners, pediatricians and health systems to find ways to implement the more effective vaginal testing method for STI detection, despite already accepted clinical practices of urine sampling. This also includes managing patient and guardian expectations and providing education on the more effective vaginal test.

Growing Evidence Supports an Implementation Shift Toward Vaginal Sampling for Chlamydia trachomatis, Neisseria gonorrhea, and Trichomonas vaginalis Screening

Sarah M. Wood, MD, MSHP, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Division of Adolescent Medicine, Children’s Hospital of Philadelphia (CHOP), and Clinical Futures, CHOP, Philadelphia, Pennsylvania

Alexander Fiks, MD, MSCE, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of General Pediatrics and Clinical Futures, CHOP, Philadelphia, Pennsylvania

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Patients with Chronic Pain Value Empathic Doctors Who Validate Concerns and Communicate Clearly

Researchers measured the associations among process, outcomes and patient satisfaction within general medical care for chronic low back pain, provided through an ongoing patient-physician relationship. They also used two models to measure factors associated with patient satisfaction, including studying a subgroup of participants experiencing chronic low back pain who were being treated by the same physician for more than five years.

Among 1,352 participants, only physician empathy and physician communication were associated with patient satisfaction in the multivariable analysis that controlled for potential confounders. Similarly, in the subgroup of 355 participants, physician empathy and physician communication remained linked to patient satisfaction in the multivariable analysis.

Physician empathy and physician communication were strongly associated with patient satisfaction with medical care for chronic low back pain. Researchers argue that patients with chronic pain highly value physicians who are empathic and who make efforts to more clearly communicate treatment plans and expectations.

What is Known on This Topic: Despite medical advances in managing chronic pain experienced by millions of Americans, little research has been conducted on how patient-physician interaction impacts the process of delivering medical care for chronic low back pain and, ultimately, patient satisfaction.

What This Study Adds: Patients with chronic pain highly value empathic physicians who validate their concerns and often ill-defined symptoms, as well as physicians who make efforts to more clearly communicate treatment plans and expectations to patients.

Patient Satisfaction With Medical Care for Chronic Low Back Pain: A Pain Research Registry Study

John C. Licciardone, DO, MS, MBA, et al,

University of North Texas Health Science Center, Fort Worth, Texas

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Clinics Use Toolkit to Assess Patients’ Physical, Environmental, Lifestyle, Social, Emotional, Mental and Spiritual Experiences With Healthcare Team

The HOPE Note Toolkit is being used in some healthcare systems to improve whole person care. In order to support clinics in the process of adopting the HOPE Note Toolkit in primary care, researchers tested a learning collaborative approach across 17 primary care clinics in the United States, including private practices and family medicine residency training programs. The collaborative used expert and peer supported practice improvement and action research to help clinical teams develop the skills and processes needed to conduct whole person integrative health visits using the toolkit.

The 16 participating clinics represented more than 220 clinicians serving approximately 39,000 patients. Most clinics planned to expand their use of the tools and reported improved knowledge, skills and delivery of whole person care.

What is Known: Providing primary care has transitioned from simply treating a patient’s medical conditions to taking into account the many factors that affect a person’s health, including their physical, environmental, lifestyle, social, emotional and mental health, as well as their spirituality. It is challenging to change practice patterns to address these various aspects of whole person care.

What the Innovation in Primary Care Adds: A learning collaborative approach supported the adoption of the HOPE Note Toolkit for the delivery of whole person care in 16 primary care practices.

Implementing Whole Person Primary Care

Elena Rosenbaum, MD, et al

Department of Family and Community Medicine, Albany Medical College, Albany, New York

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Integrating Patients’ Social Determinants of Health Into the EHR, Along with Clinic Conversations, Can Help Doctors Provide More Personalized and Preventive Care

A recent study conducted in a large nonprofit network of community health centers assessed the extent to which patients’ social determinants of health influence safety-net primary care clinicians’ decisions at the point of care, and how that information came to the clinician’s attention. Descriptive statistics and generalized estimating equation models were used to assess relationships between clinician, patient and encounter characteristics and clinicians’ reported use of social determinants of health data in clinical decision-making.

Social determinants of health influenced care in 35% of surveyed encounters. Most common sources of information on patients’ social determinants of health were conversations with patients (76%); prior knowledge of the patient’s social determinants of health (64%); and social determinants of health information documented in the EHR (46%). Social determinants of health were significantly more likely to influence care for male and non-English-speaking patients, and those with social determinants of health screening data documented in discrete (i.e., more easily measurable and reportable) fields in the EHR. The authors assert that EHRs present an opportunity to support clinicians in integrating information about patients’ social and economic circumstances into care planning.

What is Known on This Topic: Although there is increased interest in conducting social risk screening in primary care settings and in how that knowledge might impact patient outcomes, little is known about how and whether social risk information influences clinicians’ decisions at the time the patient presents in the clinic.

What This Study Adds: Using an EHR-embedded card study, which is a unique method of obtaining information about patient-clinician interactions, the research team found that the combination of discrete social determinants of health information and directed conversations are likely to provide the nuanced data that enable personalized care.

Patient-Reported Social Risks and Clinician Decision Making: Results of a Clinician Survey in Primary Care Community Health Centers

Arwen Bunce, MA, et al

OCHIN Inc., Portland, Oregon

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A Comprehensive Tool Measuring Burden of Chronic Conditions Shows Valid and Reliable Results Compared to Clinical Surveys in Patients with COPD, Diabetes, Asthma

Researchers evaluated the Assessment of Burden of Chronic Conditions (ABCC) scale, developed to improve care by facilitating shared decision making and self-management. The scale assesses and visualizes the patient’s experience of one or multiple chronic conditions, and integrates it in daily care. The researchers determined it is valid and reliable in people with Chronic Obstructive Pulmonary Disease (COPD), asthma or Type 2 Diabetes Mellitus (T2DM). They compared the ABCC scale with other clinical questionnaires to assess validity, consistency and reliability.

A total of 65, 62 and 60 people with COPD, asthma and T2DM, respectively, were included in the study. The ABCC scale correlated higher than the cut-off point for construct validity in 75% of the comparisons with the Saint George Respiratory Questionnaire; 100% of the comparisons with the Standardized Asthma Quality of Life Questionnaire (100%); and 75% of the comparisons with the Audit of Diabetes-Dependent Quality of Life Questionnaire. The team also found the ABCC scale was internally consistent and had good test-retest reliability for people with the three chronic conditions. They concluded that the ABCC scale is a valid and reliable questionnaire that can be used within the ABCC tool for people with COPD, asthma or T2DM. They recommend that future research determine whether this applies to people with multimorbidity, and what the effects and experiences are upon clinical use.

What is Known on This Topic: Currently, most existing questionnaires in clinical practice focus on measuring a patient’s quality of life with respect to a single disease, failing to include the full scope of burden of disease from multiple, chronic conditions.

What This Study Adds: The Assessment of Burden of Chronic Conditions tool, which was designed to measure burden of disease, and to facilitate shared decision making, self-management and patient-health care physician communication about experienced burden and burden-guided care plans, is a valid and reliable questionnaire that can be used among people with COPD, asthma or T2DM.

Validity and Reliability of the Assessment of Burden of Chronic Conditions Scale in the Netherlands

Danny Claessens, MSc, et al

Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands

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Study Indicates that Proactive Patient Education and Recruitment Can Help Improve Lung Cancer Screening Rates in the Primary Care Setting

Researchers examined the impact of a proactive patient education/recruitment program in a primary care setting on improving screening rates by low-dose computed tomography (LDCT) for lung cancer. They used a nurse navigator to help identify eligible patients for screening from the EMR and to contact them directly to provide preliminary pre-screening counseling and education on screening and smoking cessation.

Of the 451 current/former smokers in the study’s retrospective phase, 184 were eligible for LDCT. Of the 184 patients, 34 had LDCT ordered; 32 completed LDCT; and 10 had a lesion, while 150 did not undergo LDCT. In the prospective phase, among the 451 current/former smokers, 189 were eligible for screening; 22 had LDCT; 17 had a diagnostic CT; and 150 required LDCT. The nurse navigator identified an additional 56 patients as eligible upon contacting those with incomplete smoking histories. In total, 206 patients were eligible for LCDT, an increase of 37.3% compared to the retrospective phase. Of the 206 eligible patients, 122 verbally agreed to screening; 94 met with their physician; and 42 were prescribed a LDCT.

Researchers found that using a proactive education/recruitment model identified 37.3% more eligible patients for LDCT. Fifty-nine percent of eligible patients verbally agreed to a screening. The authors argue that it is essential to identify strategies, like the ones that they used, to increase LDCT screenings among willing and eligible patients.

What is Known on This Topic: While lung cancer is a leading cause of cancer deaths, in 2011 the National Lung Screening Trial showed a 20% reduction in lung cancer mortality with the use of an annual low-dose computer tomography (LDCT) screening. Despite Medicare coverage for LDCT screening, only a small percentage (5.8%) of eligible individuals received the life-saving screening in 2022.

What This Study Adds: Study authors find that through the use of proactive education and recruitment strategy, administered with the help of a nurse navigator, more eligible individuals can be identified, learn more about the screening process, and undergo the procedure.

Proactive Recruitment Strategy for Patient Identification for Lung Cancer Screening

Traves Crabtree, MD, et al

Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University, Springfield, Illinois

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COVID-19 Impacted Smoking Assessment Rates in Community Health Centers, Necessitating a Closer Examination on How Procedures Can be Adapted

Researchers from Oregon Health & Science University and OCHIN, a large nonprofit network of community health centers, extracted electronic health record data from 217 primary care clinics between January 2019 through the end of July 2021, which included telehealth and in-person visits for 759,138 adult patients aged 18 and older years to determine how monthly rates of tobacco assessment had been affected by the COVID-19 pandemic. The team calculated the rates per 1,000 patients. The team found that between March and May 2020, tobacco assessment monthly rates declined from 155.7 per 1,000 patients down to 77.7 per 1,000 patients, a 50% decline. There was a subsequent increase in tobacco assessment between June 2020 and May 2021. However, assessments remained 33.5% lower than pre-pandemic levels. These findings are significant given the fact that tobacco use can increase the severity of COVID-19 symptoms.

What is Known on This Topic: While there is plentiful evidence on the impact that COVID-19 has had on primary health care seeking and delivery, little is known about how the pandemic affected tobacco use assessments and cessation programs.

What This Study Adds: The decline in the rate of tobacco assessments during the onset of the COVID-19 pandemic was substantial and rates have yet to return to pre-pandemic levels. Given that tobacco use can exacerbate COVID-19 symptoms, researchers recommend careful examination of procedural changes to adapt care delivery to support community health centers, specifically tobacco cessation efforts.

.Impact of COVID-19 Pandemic on Assessing Tobacco Status in Community Health Centers

Susan A. Flocke, PhD, et al,

Department of Family Medicine, Oregon Health & Science University, Portland, Oregon

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Comprehensiveness is Falling Among Family Physicians at All Career Stages in Canada

Canadian researchers describe changes in the comprehensiveness of services delivered by family physicians in four Canadian provinces (British Columbia, Manitoba, Ontario, and Nova Scotia) between 1999/2000 and 2017/2018, and explore if changes differ by the number of years physicians are in practice. They argue that having an accurate picture of changes in comprehensiveness can inform policy responses. They measured comprehensiveness using province-wide billing data across seven settings (home, long-term care, emergency department, hospital, obstetrics, surgical assistance, anaesthesiology) and seven service areas (pre/post-natal care, pap testing, mental health, substance use, cancer care, minor surgery, and palliative home visits). They found that comprehensiveness declined in all provinces, with greater changes in the number of settings than service areas. Declines were no greater among new-to-practice physicians than those who had 10 or more years of service.

While comprehensiveness has declined over time among physicians entering practice, this decline occurred across all career stages in the study’s time periods. Findings are consistent across the four Canadian provinces the team examined. The authors argue that any efforts to enhance or maintain comprehensive family medicine services should address the service delivery contexts in which all primary care physicians are practicing, rather than interventions in training or early practice.

What is Known on This Topic: Comprehensive family physician service has declined across multiple Canadian provinces over the last 20-plus years, prompting speculation that this is due to young physicians’ lack of interest in delivering comprehensive primary care or that they are receiving inadequate training in providing comprehensive primary care.

What This Study Adds: Researchers found that family physicians are practicing in fewer settings (e.g. home, long-term care, hospital) but this is not correlated with a physician’s number of years in practice. Since this doesn’t correlate with the number of years in practice, it suggests that the decrease in comprehensive care is not due to a lack of interest or training specific to younger physicians.

Declining Comprehensiveness of Services Delivered by Canadian Family Physicians Is Not Driven by Early-Career Physicians

M. Ruth Lavergne, MSc, PhD, et al

Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, and the Canada Research Chairs Program, Tier II Primary Care, Ottawa, Ontario, Canada

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Primary Care Program Promoting Senior Health Demonstrated Acceptable Reach and Adoption But Lacked Clinical Benefits

Researchers evaluated the feasibility of implementing the Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) primary care program across multiple sites, and the reproducibility of the effects found in a previous randomized controlled trial (RCT). Health TAPESTRY is aimed at helping older adults stay healthier longer. The study was a pragmatic, unblinded, six-month parallel group RCT. Eligible patients were 70 years and older, receiving care from one of six participating interprofessional primary care practices (both urban and rural). In total, 599 patients (301 intervention, 298 control) were recruited from March 2018-August 2019. Intervention participants received a home visit from volunteers to

collect information on physical and mental health, as well as their social environment. An interprofessional care team then created and implemented a care plan. The primary outcomes were the amount of physical activity and number of hospitalizations.

Researchers found that Health TAPESTRY had widespread reach and adoption, based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. In the intention-to-treat analysis (257 intervention, 255 control), there were no statistically significant between-group differences for hospitalizations and total physical activity. There were 37 non-study related serious, adverse events (19 intervention, 18 control). The authors found Health TAPESTRY was successfully implemented in diverse primary care practices. However, implementation did not reproduce the effect on hospitalizations and physical activity found in the initial randomized control trial.

What is Known on This Topic: A strong primary care system can meet the increasing numbers of older patients and their healthcare needs more efficiently and effectively, while also improving patient and service use outcomes through disease management and coordinated, long-term, person-focused and comprehensive care.

What This Study Adds: The adoption of a health intervention program that aligns with best-practice research and the principles of primary care – in this particular study, Health TAPESTRY – had acceptable reach and adoption across a variety of primary care settings. However, it was not effective at improving clinical outcomes.

Health TAPESTRY Ontario: A Multi-Site Randomized Controlled Trial Testing Implementation and Reproducibility

Dee Mangin, MBChB, DPH, FRNZCGP, et al

Dept. of Family Medicine, McMaster University, Hamilton, Ontario, Canada

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Preventive Medicine Leaders Describe How the USPSTF’s Current Methods are Evolving to Address Preventive Health Equity and Identify Evidence Gaps for Future Research

A team of current and former U.S. Preventive Services Task Force (USPSTF) members and staff from the Agency for Healthcare Research and Quality describe how USPSTF methods are evolving to address preventive health equity and define evidence gaps for future research. The USPSTF uses rigorous methods including comprehensive, systematic reviews addressing the benefits and harms of specific preventive services. The task force’s recommendations are used by primary care clinicians and their patients to decide together which preventive strategies are right for each person.

The team discusses how the USPSTF prioritizes topics based on disease burden; extent of new evidence; whether the service can be provided in primary care; and how, going forward, members will increasingly consider health equity. The task force uses analytic frameworks to specify key questions and linkages connecting a specific preventive service with health outcomes. Contextual questions help provide information on natural history, current practice, health outcomes in high-risk groups, and health equity. The task force assigns a level of certainty to the estimate of net benefit of a preventive service: high, moderate, or low. The magnitude of net benefit is also judged based on whether those benefits minus harms are substantial, moderate, small or zero/negative. The USPSTF uses these assessments to assign a letter grade from ‘A’ (recommend) to ‘D’ (recommend against). ‘I’ statements are issued when evidence is insufficient to recommend for or against a service.

The authors report that the USPSTF will continue to evolve its methods for simulation modeling and the use of evidence to address conditions where there is limited data for specific groups that bear a disproportionate burden of disease. Additional pilot work is underway to better understand the relationship of the social constructs of race, ethnicity and gender to health outcomes to further inform the development of a USPSTF health equity framework.

What is Known on This Topic: The USPSTF uses rigorous methods that include comprehensive systematic reviews addressing the benefits and harms of preventive services. The USPSTF’s recommendations are for primary care clinicians and their patients. This paper describes the methodology that the USPSTF uses to makes evidence-based recommendations about preventive services to improve health for people nationwide, including Black, Hispanic/Latino, Asian and Pacific Islander, and Indigenous populations that face systemic racism, which leads to higher risks of preventable diseases and a lower likelihood of receiving appropriate preventive services, diagnostic evaluations, and treatments.

What This Study Adds: The USPSTF will continue to follow its traditional, robust critical appraisal of the evidence, while working to advance innovative methods to address conditions where there is limited data for specific, disproportionately affected groups. This evolution of methods will ensure the USPSTF continues to meet its mission of improving the health of all people nationwide.

Putting Evidence Into Practice: An Update on the US Preventive Services Task Force Methods for Developing Recommendations for Preventive Services

Michael J. Barry, MD, et al

Division of General Internal Medicine, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts

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Doctor Challenges Colleagues to Embrace ‘Counterculture Professionalism’ to Mobilize Primary Healthcare Reform

In this essay, Kevin Grumbach, MD, argues that it is unreasonable for family physicians and their allies committed to ensuring that all Americans have access to high-quality primary care to overcome decades of policy failures without adopting different tactics to change those policies. He contends that primary care is a common good, echoing the position of the National Academies of Sciences, Engineering, and Medicine report on primary care published in 2021. However, he asserts that a profit-oriented, market-based health system does not promote primary care as a common good and in fact serves as a structural barrier to reaping primary care’s benefits. He issues a bold call for a Primary Care for All program – a tax-financed system of universal coverage for primary care funded at twice the level of current spending on primary care in the US. He adds that professionalism in primary care has both aided and constrained those in the profession and that primary care doctors must embrace what he calls “counterculture professionalism” to join with fellow primary care workers, patients and other partners to build a broad social movement to challenge entrenched interests and demand fundamental restructuring of the health system and the democratization of health. “Family physicians must ignite a flame of ‘counterculture professionalism’ to exercise moral authority and be trustworthy partners in a democratic movement to liberate primary care as a common good,” Grumbach writes. “The path to well-supported primary care will not be found in taking comfortable roads that, in the past, never arrived at their desired destination.”

Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good

Kevin Grumbach, MD

Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco, California

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